Spinal Cord Stimulator (SCS) Placement: Examining Outcomes Between the Open and Percutaneous Approach.

BACKGROUND: Spinal cord stimulator (SCS) placement has been gaining traction as an approach to modulate pain levels for several different chronic pain conditions. This procedure can be performed via a percutaneous or open approach. Data regarding SCS complications are relatively limited. OBJECTIVE: The purpose of this study was to leverage a large national database to examine outcomes between the percutaneous and open SCS placement approaches. Outcomes in this study include length of stay (LOS), complication rates, reoperation rates, and 1-year readmission rates. MATERIALS AND METHODS: Inclusion criteria for the current study is SCS placement between 2015 and 2020, with receipt of an SCS using either a percutaneous approach or an open laminectomy based approach. Encounters included were limited to true SCS placement, such that trial placements were not included in the study. Univariate statistics and multivariable logistic regression was performed to compare outcomes between cohorts. RESULTS: Total SCS case volumes were 9935 between the percutaneous (n = 4477, 45.1%) and open (n = 5458, 54.9%) approach. Patients receiving the percutaneous approach were found to have a mean decrease in LOS of 9.91 hours when compared to those receiving the open approach. The percutaneous approach was significantly associated with the need for reoperation within one year compared to the open approach (odds ratio [OR]: 0.663, p < 0.001), as well as with the need for readmission within 30 days (51.2% vs 40.2%, OR: 0.759, p < 0.001). CONCLUSION: The open approach, when compared to the percutaneous approach, had a longer mean LOS, lower outpatient discharge rates, and higher odds of experiencing an operative complication in comparison to the percutaneous approach. The percutaneous approach had relatively increased odds of thirty-day readmission, although no significant difference in one-year readmission or removal was demonstrated.

The Association of Psychiatric Comorbidities With Short-Term and Long-Term Outcomes Following Spinal Cord Stimulator Placement.

BACKGROUND: Outcomes after spinal cord stimulator (SCS) placement are affected by psychologic comorbidities. It is part of routine practice to do psychologic assessments prior to SCS trials to assess for the presence of maladaptive behavioral patterns. However, few studies have sought to quantify the effect of psychiatric comorbidities on complications, reoperation, and readmission rates. The purpose of this study was to assess the association of psychiatric comorbidities with postprocedural outcomes after SCS implantation. MATERIALS AND METHODS: Inclusion criteria included SCS placement between 2015 and 2020 (percutaneous approach or an open laminectomy-based approach) using Healthcare Corporation of America National Database. Data on psychiatric comorbidities present at the time of SCS implantation surgery were collected. Outcomes of interest included complication rates (defined as lead migration, fracture, malfunction, battery failure, postoperative pain, infection, dural puncture, or neurological injury), reoperation rates (defined as either revision or explant [ie, removal]), and readmission rates within 30-day and 1-year time after SCS implantation. We measured the association between psychiatric comorbidities and outcomes using multivariable regression and reported odds ratio (OR) and respective 95% confidence intervals. RESULTS: A total of 12,751 cases were included. The most common psychiatric comorbidities were major depressive disorder (16.1%) and anxiety disorder (13.4%). In unadjusted univariate analysis, patients with any psychiatric comorbidity had heightened rates of any complication (27.1% vs 19.4%), infection (5.9% vs 1.9%), lead displacement (2.2% vs 1.3%), surgical pain (2.1% vs 1.2%), explant (14.7% vs 8.8%), and readmission rates at one year (54.2% vs 33.8%) (all p < 0.001). In multivariable logistic regression, with each additional psychiatric comorbidity, a patient had increased odds of experiencing any complication (OR = 1.5, 95% CI = 1.36-1.57, p < 0.001), requiring a reoperation (OR = 1.5, 95% CI = 1.37-1.6, p < 0.001), and requiring readmission (OR = 1.7, 99% CI = 1.6-1.8, p < 0.001). CONCLUSIONS: The presence of psychiatric comorbidities was found to be associated with postoperative complication rates, reoperation, and readmission rates after SCS placement. Furthermore, each consecutive increase in psychiatric comorbidity burden was associated with increased odds of complications, reoperation, and readmission. Future studies might consider examining the role of presurgical mental health screening (ie, patient selection, psychologic testing) and treatment in optimizing outcomes for patients with psychiatric comorbidities.

Long-Term Outcomes After Spinal Cord Stimulator Placement in Patients with Pre-procedural Active Opioid Use Versus Patients Who Were Opioid-Naïve.

BACKGROUND: Outcome optimization after the placement of a spinal cord stimulator (SCS) is critical. The objective of this study was to determine if an association existed between pre-procedural opioid use (compared to patients who were opioid-naïve) and postoperative long-term outcomes following SCS placement. OBJECTIVE: To examine the impact of preprocedural opioid use on long-term outcomes after SCS therapy. STUDY DESIGN: Cohort study utilizing a nationwide database. SETTING: Retrospective. METHODS: With the use of data from HCA Healthcare's national database, a retrospective cohort study was performed to analyze differences in outcomes between opioid-naïve patients and preoperative opioid users who underwent SCS placements. The primary outcome of interest was device explantation at 6 months and 12 months. Secondary outcome measurements included reoperations and readmissions at 6 months and 12 months, as well as operative complications. Multivariable logistic regression models were performed to analyze the association of preoperative opioid use with those outcomes. The odds ratio (OR), 95% confidence intervals (CI), and P values were reported for the independent variables. RESULTS: The final study population consisted of 13,893 patients who underwent SCS placements. In univariate analyses, patients who used opioids preoperatively had higher 6-month (3.6% vs. 2.6%) and one-year removal rates (3.6% vs. 2.8%) (all P < 0.009). On multivariable logistic regression, those using opioids preoperatively had higher odds of removal at 6 months (OR = 1.290, 95% CI 1.05-1.58, P = 0.01) and at one year (OR = 1.23, 95% CI 1.01-1.50, P = 0.04). There was no difference between patients requiring preoperative opioids and patients who were opioid-naive as far as the odds of 6- or 12-month readmissions were concerned. Compared to the opioid-naive group, patients requiring preoperative opioids had increased odds of reoperation at 6 months (OR = 1.2, 95% CI 1.02-1.40, P = 0.03). There were no differences in the odds of complications between both cohorts. LIMITATIONS: Opioid use in this study was defined as using opioids preoperatively in the 30 days leading up to surgery. CONCLUSION: Patients requiring preoperative opioids before SCS placements had increased odds of SCS explantation at 6 months and 12 months, as well as increased odds of reoperation at 6 months.

Factors Associated With Same Day Discharge Post-Spinal Cord Stimulator Placement.

BACKGROUND: Spinal cord stimulator (SCS) surgeries, whether performed using the open or percutaneous approach, are becoming increasingly common for a range of neuropathic pain conditions, including post-laminectomy syndrome and complex regional pain syndrome. However, there is limited knowledge regarding the factors linked to same-day discharge patterns following SCS. OBJECTIVE: The purpose of this study was to identify factors associated with same-day discharge after SCS placement. The primary outcome was same-day discharge. STUDY DESIGN: Retrospective, cohort study using a nationwide database. METHODS: Inclusion criteria included patients who underwent percutaneous or open SCS from January 1, 2014 through December 31, 2021. Exclusion criteria included patients with missing data (n = 178) and those with SCS implants for unlisted indications (n = 1,817). A multivariable analysis was conducted on the outcome data and co-variates associated with same-day discharge after SCS. RESULTS: After applying inclusion and exclusion criteria, a total of 18,058 patients remained in the final data set, including 7,339 patients who underwent percutaneous SCS and 10,719 patients who underwent open SCS procedures. After analysis, factors associated with increased rates of same-day discharge after SCS included men (odds ratio [OR] 1.16; 95% CI, 1.09 -1.24;  P < 0.001), patients on Medicaid (OR 1.64; 95% CI, 0.1.34 - 2.01; P < 0.001), and hospitals in the US Midwest (OR 1.66; 95% CI, 1.45 - 1.90; P < 0.001) and hospitals in the US West (OR 1.32; 95% CI, 1.20 - 1.46; P < 0.001). Factors associated with decreased rates of same-day discharge after SCS included the open approach (OR 0.21; 95% CI, 0.19 - 0.23; P < 0.001), Hispanic ethnicity (OR 0.61; 95% CI, 0.54 - 0.69; P < 0.001) and increased age (OR 0.99; 95% CI, 0.98 - 0.99; P < 0.001). LIMITATIONS: Since our study is retrospective, the data are subject to various biases, including variable confounding, human error in data entry, and generalizability of the results. CONCLUSION: These results can be used to help determine hospital bed needs post-SCS surgery. Future research should focus on identifying the specific reasons certain demographic and geographic factors might influence same-day discharge rates. Our study provides important insights into the factors associated with same-day discharge rates post open and percutaneous SCS implant and highlights the need for patient-centered, evidence-based approaches to health care delivery.

Association of patient characteristics with the receipt of regional anesthesia.

BACKGROUND: Regional anesthesia (RA) may improve patient-related outcomes, including decreased operative complications, shortened recovery times, and lower hospital readmission rates. More analyses are needed using a diverse set of databases to examine characteristics associated with the receipt of RA. METHODS: A national hospital database was queried for patients 18 years or older who underwent total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, ankle open reduction, and internal fixation and arteriovenous fistula creation between January 2016 and June 2021. Regional techniques included neuraxial anesthesia and various upper and lower extremity peripheral nerve blocks to create a binary variable of RA receipt. Univariate statistics were used to compare characteristics associated based on RA receipt and multivariable regression identified factors associated with RA receipt. RESULTS: A total of 51 776 patients were included in the analysis, of which 2111 (4.1%) received RA. Factors associated with decreased odds of RA receipt included black race (vs white race; OR 0.73, 95% CI 0.62 to 0.86), other non-white race (vs white race; OR 0.71, 95% CI 0.61 to 0.86), American Society of Anesthesiologists (ASA) class (vs ASA 1; OR 0.85, 95% CI 0.79 to 0.93), and Medicaid insurance (vs private insurance; OR 0.65, 95% CI 0.51 to 0.82) (all p<0.05). When compared with TKA, ACLR (OR 0.67, 95% CI 0.53 to 0.84), ankle open reduction and internal fixation (OR 0.68, 95% CI 0.58 to 0.81), and carpal tunnel release (OR 0.68, 95% CI 0.59 to 0.78) demonstrated lower odds of RA receipt, whereas TSA (OR 1.31, 95% CI 1.08 to 1.58) demonstrated higher odds of RA receipt (all p<0.05). CONCLUSION: RA use varies with respect to race, insurance status, and type of surgery.

Differences in Regional Anesthesia Utilization by Hospital Region in the United States.

BACKGROUND: Regional anesthesia has been associated with improved postoperative outcomes. Disparities in regional anesthesia utilization exist; however, no studies have examined utilization rates as a function of hospital region. METHODS: A national hospital database (Hospital Corporation of America {HCA}) was queried for patients aged 18 years or older that received selected surgical procedure codes between January 2016 and June 2021. Surgical procedures included were total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, total abdominal hysterectomy (TAH), open reduction and internal fixation (ORIF) of the ankle, and arteriovenous (AV) fistula creation. Regional anesthesia was defined as any form of neuraxial and/or peripheral nerve blocks. Basic summary statistics were utilized to calculate the rates of regional anesthesia (RA), and chi-squared analyses were calculated to determine significant differences in the rate of RA utilization. RESULTS: There were 52,068 patients included in this study, of which 2,114 (4.1%) received RA. The greatest RA rates were for TSA (5.8%), TKA (4.5), and anterior cruciate ligament reconstruction (ACLR) (3.6%), whereas the lowest RA rate was for TAH (1.1%). For the TKA cohort, the Midwest had a significantly greater utilization rate than the South or West (10.9% vs. 4.8% or 3.1%, p<0.001). The Midwest also had the highest utilization rate in the ACLR cohort (8.1%, p<0.001), TAH cohort (16.7%, p<0.001), and AV fistula cohort (6.4%, p<0.001). For the carpal tunnel cohort, the West had the highest utilization rate (11.8% vs. 8.1%, 1.1%, 0%, p<0.001). The West region also had the highest utilization rate for the ankle ORIF (7.8%, p<0.001). No significant differences were found by region for TSA (p=0.31). CONCLUSION: Significant variations in RA utilization rates were found by region, with the West having the highest utilization for ankle ORIF and carpal tunnel, and the Midwest having the highest rate for TKA, ACLR, TAH, and AV fistula.

Foreign Body in the Glottis.

This case report highlights some of the anesthetic challenges of an airway foreign body removal. We present a case report of foreign body removal in a 50-year-old male with an oxtail bone lodged between the vocal cords. We used face mask general anesthesia with sevoflurane.

Muir-Torre Syndrome: Abdominal Sebaceous Carcinoma.

A 56-year-old male with a past medical history of arachnoid cysts and with two previous brain operations and a ventriculoperitoneal shunt presented with a large left lower quadrant (LLQ) abdominal mass for one year, growing rapidly for the past three months. He endorsed pus and blood leaking from ulceration on the lateral underside of the mass, and a section of the mass ruptured with blood and pus draining out on the day of admission. He denied any fevers, chills, pain, or numbness in the mass or any history of similar masses. Of note, the patient has an extensive familial history of cancer including colorectal cancer in his mother in her 30s. Computed tomography and biopsy of mass were concerning for malignancy, reporting a neoplasm in the dermis that grows in round and irregular lobules of cells along with the majority of the cells having oval nuclei with areas of sebaceous differentiation. Pathology showed sebaceous carcinoma with concern for Muir-Torre syndrome. The patient was discharged and instructed to follow up with oncology and gastroenterology.

Autobiographical Case Report of Experiences With Pleomorphic Xanthoastrocytoma.

Pleomorphic xanthoastrocytoma is a rare brain tumor of WHO grade II designation. This case report describes the author's experience with the discovery of the tumor, living with the tumor, and eventual treatment and aftermath of how it affected her life and her understanding of the medical system.